Out Of Existence Withdrawal Affidavit {REV-238}

REV-238 CM (04-13) DEPARTMENT USE ONLY BUREAU OF COMPLIANCE OUT OF EXISTENCE/MERGER SECTION PO BOX 280947 HARRISBURG PA 17128-0947 717-783-6052 TT# 800-447-3020 (Services for taxpayers with special hearing and/or speaking needs only) OUT OF EXISTENCE/WITHDRAWAL AFFIDAVIT Revenue ID PLEASE PRINT OR TYPE INFORMATION THIS FORM MUST BE PROPERLY SIGNED AND NOTARIZED NOTE: · If filing a final RCT-101 corporate report for 2002 and forward, complete the "corporate status change" section in the RCT-101 in lieu of filing this form. · The reverse side of this form must be completed. Section A pertains to a PA corporation or a foreign corporation that operated wholly within Pennsylvania. Section B pertains to all other foreign corporations. · If you wish to be notified by email that the corporation is out of business, please provide email address on reverse side. Date of Incorporation or Certificate of Authority State of Incorporation Name of Corporation/Taxpayer I, the "Affiant," was connected with the above corporation and have knowledge of its affairs. Said corporation ceased to transact business in Pennsylvania on or about* distributed on Month Month Day Day Year Year Account ID/Revenue ID Entity ID (EIN) , and all assets were sold, assigned or , and since that time, the corporation has not owned any property located in Pennsylvania, nor maintained an office therein, nor has performed any sales activity and does not intend to transact further business in the commonwealth. *If corporation never transacted business or held assets in Pennsylvania, please use the words "NEVER TRANSACTED BUSINESS" in place of a cessation date. The filing of this affidavit does not affect the status of the Certificate of Incorporation/Authority of this corporation but does permit the Department of State to relinquish the use of the present name of the corporation to another corporation. This affidavit is not to be filed by a PA corporation utilizing its PA charter to conduct business in another state. Out-of-state corporations soliciting business in Pennsylvania are subject to tax and should file this document only upon ceasing activity in Pennsylvania. Sworn to and subscribed before me this day of (Notary Public, District Justice or Authorized Agent, Department of Revenue) , year (Signature of Affiant) TITLE My commission expires , year Telephone Number ( (Present address of Affiant) ) (Notary Signature and Seal) PLEASE PRINT OR TYPE INFORMATION NO FILING FEE American LegalNet, Inc. www.FormsWorkFlow.com THIS SCHEDULE MUST BE COMPLETED. ENTER "NONE" ONLY IF THE CORPORATION HAS NO ASSETS AND/OR LIABILITIES. Name of Corporation Business Address City State ZIP Code DISTRIBUTION OF ASSETS Please Print or Type Revenue ID/ Corp. Box # Date of Final Distribution A. CORPORATION OPERATING 100% WITHIN PA MUST COMPLETE THIS SECTION (Provide copies of Federal Form 1099-DIV) Stockholder Name Street Address Stockholder Name Street Address Stockholder Name Street Address Stockholder Name Street Address Stockholder Name Street Address City City City City City Social Security Number State ZIP Code SHARES OF STOCK OF EACH STOCKHOLDER NUMBER PAR VALUE MONEY RECEIVED BY EACH STOCKHOLDER DATE AMOUNT DATE AMOUNT AND NATURE OF OTHER ASSETS RECEIVED BY EACH STOCKHOLDER DESCRIPTION AMOUNT Social Security Number State ZIP Code Social Security Number State ZIP Code Social Security Number State ZIP Code Social Security Number State ZIP Code B. CORPORATIONS WITHDRAWING FROM PA BUT CONTINUING OPERATIONS OUTSIDE OF PA MUST PROVIDE THE FOLLOWING INFORMATION AND/OR DOCUMENT(S). 1. FULL DETAILS OF DISPOSITION OF PA PROPERTY. ATTACH COPIES OF FEDERAL SCHEDULE D AND/OR FEDERAL FORM 4797, IF APPLICABLE. 2. PLEASE INDICATE IF SALES IN PA WILL CONTINUE AFTER DATE OF CESSATION. IF SO, HOW WILL THEY BE NEGOTIATED AND BY WHOM? ATTACH STATEMENT CONTAINING THE REQUIRED INFORMATION IF ADDITIONAL SPACE IS NEEDED. IF ANY INDIVIDUAL OR CORPORATION OTHER THAN STOCKHOLDERS AND CREDITORS RECEIVED ASSETS, LIST NAMES AND ADDRESSES OF EACH AND AMOUNT OR VALUE RECEIVED BY EACH. IF ANY CONSIDERATION WAS PAID FOR ANY OF THE ASSETS, STATE NAME AND ADDRESS OF INDIVIDUAL OR CORPORATION MAKING SUCH PAYMENT AND EXACT AMOUNT PAID BY EACH. (ATTACH A SEPARATE SHEET TO THIS FORM.) IF ANY MONEY OR PROPERTY REMAINS UNDISTRIBUTED, STATE AMOUNT, NATURE AND VALUE OF SAME, AND STATE WHY IT HAS NOT BEEN DISTRIBUTED. (ATTACH A SEPARATE SHEET TO THIS FORM.) IF ANY REAL ESTATE HAS BEEN DISTRIBUTED OR SOLD WITHIN THE FINAL TAX PERIOD, GIVE THE DATE OF RECORDING TITLE TRANSFER WITH LOCAL RECORDER OF DEEDS. DATE: EMAIL: Name of Person Making this Report Current Street Address Signature City Title State Date ZIP Code American LegalNet, Inc. www.FormsWorkFlow.com